NRC Form 4, Cumulative Occupational Dose History

OMB 3150-0005

The NRC Form 4 is used to record the summary of an occupational worker’s cumulative occupational radiation dose, including prior occupational exposure and the current year’s occupational radiation exposure. The NRC Form 4 is used by licensees, and inspected by the NRC, to ensure that occupational radiation doses do not exceed the regulatory limits specified in 10 CFR 20.1501.

The latest form for NRC Form 4, Cumulative Occupational Dose History expires 2023-11-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form NRC Form 4 NRC Form 4, Cumulative Occupational Dose History Form and Instruction
2023 Final Supporting Statement NRC Form 4.docx Supporting Statement A
NRC Form 4, Cumulative Occupational Dose History Form and Instruction

All Historical Document Collections

202311-3150-004 Approved without change	Extension without change of a currently approved collection	2023-11-21
202007-3150-005 Approved without change	Extension without change of a currently approved collection	2020-07-28
201706-3150-007 Approved without change	Revision of a currently approved collection	2017-07-21
201403-3150-003 Approved without change	Revision of a currently approved collection	2014-03-27
201403-3150-001 Withdrawn and continue	Revision of a currently approved collection	2014-03-18
201006-3150-005 Approved without change	Revision of a currently approved collection	2010-10-28
200903-3150-001 Approved with change	No material or nonsubstantive change to a currently approved collection	2009-03-04
200711-3150-005 Approved without change	Revision of a currently approved collection	2007-11-28
200708-3150-001 Approved without change	Revision of a currently approved collection	2007-08-15
200612-3150-001 Preapproved	Revision of a currently approved collection	2006-12-05
200408-3150-002 Approved without change	Revision of a currently approved collection	2004-08-13
200107-3150-005 Approved without change	Revision of a currently approved collection	2001-07-30
199807-3150-003 Approved without change	Revision of a currently approved collection	1998-07-15
199804-3150-004 Approved with change	No material or nonsubstantive change to a currently approved collection	1998-04-21
199506-3150-001 Approved without change	Revision of a currently approved collection	1995-06-23
199207-3150-009 Approved without change	Revision of a currently approved collection	1992-07-16
199106-3150-003 Approved without change	Reinstatement with change of a previously approved collection	1991-06-26
198906-3150-002 Approved without change	Revision of a currently approved collection	1989-06-01
198605-3150-002 Approved without change	Reinstatement with change of a previously approved collection	1986-05-07
198512-3150-002 Approved without change	Revision of a currently approved collection	1985-12-12
198509-3150-001 Withdrawn and continue	Revision of a currently approved collection	1985-09-16
198304-3150-001 Approved without change	Revision of a currently approved collection	1983-04-08
198104-3150-005 Approved without change	Revision of a currently approved collection	1981-04-01